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What measures are included in assessing Vital Signs?
- Blood Pressure
- O2 Saturation
What is the frequency of monitoring vital signs in the Hospital?
What is the frequency of monitoring vital signs in the Home Health Setting?
What is the frequency of monitoring vital signs in the Clinic?
What is the frequency of monitoring vital signs in the Skilled Nursing Facilities (SNF)?
Weekly to Monthly
The frequency of monitoring vital signs is determined by what 3 things?
- Physician's Order &/or Nursing Judgement
- Client's Condition
- Facility Standards
When do you measure Vital Signs?
- On admission to the Hospital
- Before, during and after a surgery or a procedure
- After a medication administration
- When there is a change in a client's condition
- Before, during and after a blood transfusion
What should you do to be ready to measure Vital Signs? (3 things)
- -Be organized in approach
- -Be aware of needed equipment
- -Know the baseline vital signs for the client and the normal ranges for the population
(The patient needs to be confident in you)
When should you report Abnormal Vital Signs?
Who should you report Abnormal Vital Signs to?
- The Student to the Instructor
- then to the RN
- then to the Charge RN
- then to the MD
When should you report Abnormal Vital Signs?
- When Abnormal
- When they Return to Normal or Change
How should you report Abnormal Vital Signs?
- 1st - Verbally to appropriate person
- 2nd - Document VS in patient's records
The degree of heat maintained by the body
What is the equation for body temperature?
heat produced - heat loss
The body's Internal Temp. is known as the ______ Temp.
What is the Normal Range for the body's Core Temp.?
96.2 - 100.4 F
36.2 - 38 C
Is the body's Surface Temp. higher or lower than its Core Temp.?
What 2 methods are mainly used to measure the body's Surface Temp.?
Oral & Auxillary (arm pit)
What 2 methods are mainly used to measure the body's Core Temp.?
Rectal & Tempanic (ear)
What is the body's Average Surface Temp. Range?
98 - 98.6 F
36.7 - 37 C
What is the body's thermostat? Its Thermoregulation?
Does the amount of temperature increase equate to the degree of illness?
What is more important than the increase in temp.?
patterns and continuousness
Heat Production can be a result of what 5 things?
- Metabolism (BMR - thyroid hormones)
- Skeletal Muscles (break down of fats)
- Nonshivering Thernogenesis (infants)
- Shivering (tells hypothalamus to help)
Heat Loss can be a result of what 4 things?
- Radiation (tranfer of heat w/o contact) 50 % of Heat Loss
- Convection (transfer of heat through air/water)
- Conduction (transfer w/ contact) 15 - 20 % of Heat Loss
- Evaporation (transfer occurs when water is convrted to vapor)
What type of Heat Loss is perspiration (sweating)?
What type of Heat Loss occurs when patient lays on a cold x-ray table?
Where is most of the body's heat lost?
on the skin
What factors affect your body's temperature?
Age, Hormones, Exercise, Circadium Rhythm (sleep cylce), Stress & Emotions, Environment
Body Temp. is _______ in the morning and _______ in the afternoon
Why do infants wear hats?
b/c they lose 30 % of their body's temp. through their head
Febrile means ______
Afebrile means ______
w/o Elevated temperature
Pyrexia means _______. It is a response to _______ or _______ or _______.
Fever. Bacterial or Viral infections or Tissue Injury
What is the body's temp. when it has Pyrexia?
Greater than 100.4 F (38 C)
What is the body's temp. when it has Hyperpyrexia?
Greater than 105.8 F
Is a fever always a bad thing? Why/Why Not?
- No - Up to 102.2 F can be beneficial b/c it:
- - enhances immune responce
- - kills/inhibits many microorganisms
- - enhances phagocytosis
- - causes breakdown of lysosomes
- - virally infected cells self destroy
- - releases interferons (protects cells from viruses)
What cell damage can a high temperature cause in the brain?
- Vascular Collapse
Heat Exhaustion is:
profuse diaphoresis (sweating) leading to water & electrolyte loss
Malignant Hyperthermia is a repsonse to _____
A Heatsrtoke is:
- A Medical Emergency
- Hot & Dry skin
- no sweating
What are the levels of Hypothermia?
- Mild = Less than 96.8
- Moderate = 96.7 - 82.4
- Severe = Less then 82.4
What are the causes of Hypothermia?
- cold weather
- cold water
- lack of shelter/clothing
- surgery (coldness can save cells)
What tyoe of thermometer would you use on a patient in isolation?
An Axillary temp. is _____ than an Oral temp.
1 degree cooler
A Rectal temp. is ______ than an Oral Temp.
1 degree warmer
What should you do before you administer a rectal thermometer?
- Make sure it is marked RED (Rectal)
- Lube it 1-2"
- **Stop if you feel resistance**
What would you like to do?
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